Catch them early–can we?

Photo Credit: WHO/M.Gzemska

Carolyn Kavita Tauro - CNS
“I will not take all these medicines for two years... they are very strong medicines. I won’t be able to go to school” said 12 year old Abu (name changed) as the doctor explained to him that his sputum was still positive after six months of treatment. Abu was now affected with Multi-Drug Resistant Tuberculosis (MDR-TB) and the person from whom he had contracted it was his 17 years old brother. Abu’s mother sat helpless recalling all the money she had already spent on doctors, medicines and nutritious food for her children.
According to the Global Tuberculosis Report 2012 - the first report to include an estimate on the burden of TB among children – there are over 490,000 cases and 64,000 deaths due to TB in children per year. This, in all likelihood, is an underestimate and therefore, just a tip of the iceberg. Also, the number of these deaths includes only those of HIV negative children, as HIV positive children would be classified under HIV deaths. In India, the number of notified new TB cases in 2011 was about 1.5 million (15 lakhs) with 150,000 of them being children. About 70%-80% of the children suffering from TB have it in their lungs (pulmonary TB) while the rest may be affected with extra pulmonary TB in in other parts of their body. Infants and young children often suffer from the TB associated with highest mortality, such as TB meningitis, while adolescents are more at a risk of developing the adult-type disease.

The management of TB in children has been a major challenge—much bigger than that for adults. The common symptoms of TB in children are a persistent cough, fever and weight loss or poor weight gain. The problem is that these symptoms are common to other childhood diseases, like pneumonia, and hence often lead to misdiagnosis. Moreover sputum production is very difficult in young children. Sputum collection through a gastric aspirate (putting a tube through the throat of the child) is not an easy method either. So diagnosis becomes a problem.

Another trouble with TB in children in India, like with adult TB or, for that matter, any other disease, is that more than half of the TB patients seek medical aid in the private sector. Various studies have been done to show the dearth of quality treatment regimens prescribed by private doctors. A study conducted in a city in Uttar Pradesh, found that doctors in the private sector used about 53 different regimens to treat tuberculosis while they used more than 87 regimens to deal with multi-drug resistant tuberculosis. In these circumstances, ignoring the private sector could only worsen the epidemic of MDR and XDR forms of TB. It has also been demonstrated in a study how tuberculosis in infants mimics congenital thoracic malformations, catching children when they are as young as infants and delaying treatment through misadventures in surgery.

Although the Revised National Tuberculosis Program (RNTCP) of India has drugs for children divided into categories according to weight bands, it becomes difficult at times to administer to children who are less than six years old and/or are underweight. Doctors find it difficult to prescribe exact dosage, since this means the tablets need to be cut in a certain manner. The lack of paediatric formulations for very young children means that tablets need to be crushed and fed. The tablets are large (and hence difficult to swallow) and not palatable either. Limited data on dosing of individual drugs make the task more difficult. Children have to take the same drugs as those for adults, for six months and two years, for TB and MDR-TB respectively. These drugs are, however, said to be tolerated by children very well. The importance of completing the course completely cannot be emphasized enough. “Adolescents often lie to their parents and the doctor that they are compliant with their medication. Sana, (name changed), died months after we had started her on treatment against TB. It was after her death that her family members found scores of the drug blisters below her mattress”, recalls Dr. Ancilla Tragler, Paediatrician at Holy Family Hospital, Bandra, Mumbai.

How do the children get infected with TB?

“The common causes are close contacts with a case of TB (especially with sputum smear-positive TB), in infants and children below 4 years of age or in adolescents who are immune-suppressed with HIV or malnutrition”, says renowned paediatrician Professor Steve Graham, Chair of the Child TB subgroup of WHO Stop TB Partnership and working for the International Union Against Tuberculosis and Lung Disease, Australia.

Active case finding of children living in households affected by TB is therefore essential.

“Most uncomplicated childhood pulmonary TB is non-infectious and there we need to find the adult source of infection. This would go a long was in TB control and this is something that is not done enough. Active screening of the family isn’t sought after”, adds Dr. Tragler.

Another vital preventive measure in the form of preventive therapy such as Isoniazid Preventive therapy (IPT), for children under five years of age is also not often implemented. Also, a child who is living with someone who is infected with TB can get infected, even if they are vaccinated with the vaccine for TB, Bacillus Calmette– Guérin (BCG). Although BCG doesn’t ensure protection for life from pulmonary TB, “ Its relevance in protecting children cannot be undermined as it does protect against severe and often fatal forms of TB in young children, such as TB Meningitis, and also protects against leprosy (a fact not widely known,” avers Dr Graham.

What then is the need of the hour for preventing and controlling TB in children?

Perhaps (i) a vaccine that is effective against TB for life, (ii) paediatric-friendly drug formulations along with research for short-term therapy, (iii) quality diagnostics which is cheap and child friendly so that TB can be detected as quickly as possible, and lastly (but not the least) controlling adult TB.

But can we achieve all this given that the current funding in the field of research for TB is low? To meet targets for new diagnostics of the Global Plan to Stop TB between 2011 and 2015, the required amount of funding is $1.7 billion.

But hope we shall because ‘children are one third of our population and all of our future’.

As Orison Swett Marden said, “There is no medicine like hope, no incentive so great, and no tonic so powerful as expectation of something tomorrow.”